Contemporary Boat Insurance Quote Request

If you'd like a proposal for insurance, please complete this form and press the "Submit" button at the end for a no-obligation quote. If you prefer, you can call us at 1-860-572-5908, or call our office toll free at 1-800-959-3047. You can even download our application form, print it out and fax it to us at 1-860-572-5919 or send it by mail. We'll be happy to help you.

About You

First Name: Middle Initial:    Last Name:

Date of Birth:   Email Address:

          Address, City, State, Zip:                                                                             
Phone:            This is a:   home number work number  cell phone
Fax Number:   
Please list the names and ages of any other regular operators of your boat:

Name:  Age:      
 Name:  Age:    

Have you had any marine insurance claims in the last 5 years?  Yes No

If yes, please list dates and amount of claim & briefly describe the reason for the claim:

Your years of boating experience:     Your years of boat ownership:

Please describe your boating experience.  List any previous boats owned: (type, length, number of years owned)

Have you taken any Safe Boating courses? (ex. Power Squadron or USCG Auxiliary) Yes No
Do you have a Captain's License? Yes No    Level
Are you a member ACBS or other owner's club? Yes No  Name of Owner's Club:

About Your Boat

Builder/Manufacturer's Name:   

Model:   Designer:

Length:       Year:            Boat's Name:

Boat Type:   Hull Material:

If other hull material, please describe any special construction:  

Motor Type:   Motor Manufacturer:   Motor Year:

Number of Engines:  Horsepower of Each:   Fuel:  Gas Diesel  Steam  Electric
Max Speed of Vessel:  
 Purchase Date:   Purchase Price:
Use of boat:
Private pleasure use only   Live aboard (primary residence)   Chartered (Six pack only, max. 20 per year)

Present location of Boat:   City:   State:    ZIP:

Home port of vessel

City: State:   ZIP:  

 

Vessel is kept:  in a slip at a marina     on a mooring       on a trailer       other arrangement

If other,  please describe how & where you use & keep your boat.
Waters navigated:         
Annual lay up:   From (dates):    To:    If no lay-up, check here

Lay up location: City: State:   ZIP:  

Lay Up:    Ashore     In water with a bubbler    In water without a bubbler  
Do you have a Paid Captain? Yes No    Do you employ Paid Crew Yes No   If yes, Number 
Has your Marina asked to be listed as additional insured?  Yes No 
Is there a loan on your boat?  Yes No 
 

About Your Coverage

Amount of Insurance Requested

Hull & Machinery $           Marine Liability $

 

Deductible:  

Do you want to insure your dinghy/tender?  Yes No  (Some dinghies may already be covered in our policy).

If yes, Tender Make/Manufacturer/Design    
Tender Length:     Tender Year:   TenderValue:

Do you want to insure your boat's trailer?  Yes No  

If yes, Trailer Make/Manufacturer/Design    
Trailer Length:      Trailer Year:   Trailer Value:  $  
 
Current or previous insurer :   Policy expiration date:   
Other comments: (Please add as much detail as you wish)

How Did You Hear About Us?:

 

 

 

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  Heritage Marine Insurance
PO Box 188
Mystic, CT 06355		 1-860-572-5908 local
1-800-959-3047 toll free
1-860-572-5919 fax
Email: classics@heritagemarineinsurance.com 		Express Mailing Address
Heritage Marine Insurance
11 Masons Island Road, Suite 3
Mystic, CT 06355

 
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